Wednesday, October 05, 2005

The mysteries of chest pain


So I'm having a busy and I'm *literally* in the process of walking out the door at about 9:30 am--I have to travel to a different hospital in order to run a teaching conference--when my Med Consult pager goes off. Nuts!

It's the Detox floor (where patients who want to stop taking cocaine, alcohol, etc. go for a spell in an attempt to stop using) calling, they want to me to see a woman there who just started having excruciating chest pain about 10 minutes ago. Crap. There goes the teaching conference. I page my chief & update him on the situation. He'll run it in my place.

I hurry up there, they're already giving her some nitroglycerin tablets, she's pretty agitated and crying out in pain--we slap some electrodes on her--all of this is pretty routine stuff. The EKG comes back: she has ST-elevations in her inferior leads. Holy magnarolie! This could be serious...that's a baaaaad sign for the EKG. At this point I don't have access to her old records yet for reasons I won't get into. I call the cardiologist on call and give him the scoop. "Sounds like she needs to go to the CCU right away!" he said, "I'll activate the cath lab!"

"Okie dokie," says me, "her name is XXX XXXX" (obviously I can't give the real name out).

"XXX XXXX?!?" says the Cardiologist, "Forget everything I just said...she's come in to our hospital a million times with bogus chest pain...I can give you a 100% guarantee that she isn't having a heart attack...don't send her to the CCU, she'll just be wasting a bed for somebody who needs it."

Point of the story? There are two, I guess: (1) the interpersonal relationships (e.g. between the cardiologist and the patient) are so key in determining the patient's plan of care...if she had happened to be at another hospital for Detox, she could very well have ended up having some invasive procedure done to her...which according to the data we have now probably would have been an unnessary risk to her health (once I had full access to her files, I found an old EKG which demonstrated the exact same ST elevations--suggesting that nothing NEW was going on in her heart).

And (2), why are all these people out there having chest pain? It's *very* often not related whatsoever to heart problems (although it certainly can be a warning sign of a very serious heart problem if the story fits). We have some alternative explanations in medicine (e.g. gastroesophageal reflux, panic attacks, costochondritis, etc)...but also in my experience thus far I am left without a real convincing explanation for their chest pain. I guess since I've never had any kind of chest pain myself, I find it a little odd that there are all these people out there walking around with chest pain...

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